Does anyone have a good reliable source for forms? I am in need of a auditing tool for primary care?
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Tag Archives: charts
Physician delegates to sign off their charts notes
I need help!
Since our physicians are so busy they suggested that we assign delegates to sign off their charts notes. The CMS guidelines for signature requirements does not really mentioned delegates, is this even legal to assign someone to sign off their chart notes? I do not really agree with their suggestions but if there are guidelines out there that I do not know please share them with me.
Thank you in advance
Josephine
buying interventional radiology charts
I need to buy the charts showing vascular families and color coded "selective" versus "non-selective" vessels.
ZMed Publishing sells them, but they cost $ 159.00.
Does anyone know where I can buy them for a reasonable price?
Thanks!
Flycliffyboo
confusion on how to code nuchal cord around neck in OB charts.
Hi Guys. While coding OB charts, I came across nuchal cord around neck 1. While leading through 3M there is two option to choose which is "with compression" and "with out compression". Some of my co-workers suggest that if it is around neck we have to code it as "with compression" some suggests until unless provider dose not document with compression we are not suppose to code with compression. I am very confused please any one help me with this. And how to interpret nuchal cord was tight.
Thank you.
Thank you.
Faster pace needed for reading medical charts
I have been a risk adjustment coder for almost 2 years. The companies want the job done accurately but fast. I am trying to skim the chart or speed read through but am afraid I will miss diagnoses that need to be abstracted. Does anyone have some suggestions on how to read through a chart faster and be accurate? These charts are mostly 40 to 60 pages with several DOS and many codes to look up. We have approximately 7 to 7.5 hrs a day to go through 11 charts. They keep saying to make sure you use resources to help with abstraction questions but you really don’t have time. This is risk adjustment HCC coding so you have to make sure each code can be abstracted. Thank you.
Nurse Practitioner charts countersignature?
Does anyone know if patient charts need to be countersigned by a physician? I just want to be sure that we are following current statutes or regulations. I am located in California. Thank you!